The following is part of a series of original guest columns by the American College of Physicians.
by Steven Weinberger, MD, FACP
In his column in the June 1 issue of The New Yorker, Dr. Atul Gawande used the example of McAllen, Texas, to illustrate the widely disparate spending on health care around the country. This oft cited article captured the attention of President Obama, who reportedly has made it required reading in the White House. As shown by researchers at Dartmouth and as emphasized by Dr. Gawande, increased spending does not result in higher quality care, and in fact is often associated with poorer quality care.
There are many components of higher cost health care that do not contribute to better patient outcomes, ranging from overuse or misuse of care (e.g., diagnostic testing and expensive therapeutic options) to insufficient emphasis on primary care and prevention. I would like to focus here on just one piece of the puzzle – the overuse or misuse of diagnostic testing.
Concern about potential liability
I believe there are four primary reasons for excessive diagnostic testing, although it is difficult to assess their relative importance. First is the fear of litigation when missing a diagnosis. In the case of McAllen, Dr. Gawande notes that Texas now has caps on pain-and-suffering malpractice awards, so he feels this is an unlikely explanation. Nevertheless, in many settings and for many physicians, the physician’s concern about potential liability should a diagnosis be missed likely does lead to excessive and unnecessary diagnostic testing. The presence of a cap on dollars awarded for pain and suffering may attenuate a physician’s concern about malpractice suits, but it certainly doesn’t eliminate it.
Second is the problem of poor communication across the health care system, which often results in unnecessary duplicate testing when patients are shuttled from one health care provider to another. Universal use of interoperable electronic medical records (i.e., systems that can communicate with each other) would certainly be a major step in alleviating this problem.
Conflict of interest
The third issue, unfortunately, is the conflict of interest when a physician may receive personal financial gain from diagnostic tests that he or she orders. Physician-owned laboratories and other diagnostic services, including diagnostic imaging, are the most important examples. While appropriate diagnostic testing by these physician-owned services may be fine, overuse and misuse driven by the potential for financial gain cannot be condoned.
Concern for health care costs
Finally, although this is a broad generalization, I do not think that physicians have typically embedded concern for health care costs as part of their daily diagnostic decision-making. I do not mean withholding tests that are indicated and cost-effective; I mean avoiding unnecessary testing that adds to cost without contributing to the quality of patient care.
In our medical schools and residency training programs, the emphasis on making a correct diagnosis has not been accompanied by a similar emphasis on the cost, the cost-effectiveness, and the usefulness of the various diagnostic options. Trainees as well as practicing clinicians often order tests without knowing their costs, and without taking into consideration the comparative costs of various diagnostic alternatives. At the same time, physical examination skills have been de-emphasized in favor of more expensive diagnostic studies.
Cultural shift needed
What we need is a change in culture that embraces the appropriate integration of physician-acquired information (i.e., history and physical examination) with diagnostic testing in a way that is evidence-based and takes both absolute and relative costs into consideration. This cultural shift must start with medical student and resident education, and must extend to the level of the individual practicing clinician. Why? Because the health of our health care system depends on it.
Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.